Everything You Need to Know About SOAP Notes describes the SOAP format of documentation. SOAP is an acronym for “subjective, objective, assessment, and plan”, and this form of documentation is widely used in medical, counseling, psychology, social work, and other health professions. While this format is widely used, it is sometimes not clear what information belongs under which heading and the notes are often documented incorrectly. Everything You Need to Know About SOAP Notes will provide an explanation of what is included in each section, some things that should not be included in each section, and several examples of the subjective, objective, assessment, and plan sections from medical and psychology/counseling perspectives. It will also provide you with resources to use for further research and places to find other examples and templates.
This book is ideal for graduate-level students in the medical, nursing, psychology, or counseling fields, as the SOAP format is commonly used in all of these areas. Everything You Need to Know About Soap Notes will provide examples drawn from a variety of settings.
SOAP notes are a standard format used by doctors, nurses, and other medical professionals as well as psychologists, counselors, and social workers. The primary purpose of a SOAP note is documentation of the client’s current problems, the results of any tests, examinations, or procedures, the professional’s assessment of the current problems, and a specific plan for how these will be addressed.
These notes may be very brief or very detailed, but their purpose is to contribute to the overall medical record of the client and to allow others who examine the medical record (such as other doctors treating the same patient) to review information and results. SOAP notes can help clarify and coordinate treatment between different professionals by allowing all of them to access each other’s information in a coherent format. SOAP notes can also assist in building a clearer record of the client’s history and present concerns over a period of time, by documenting what has been done in the past. This can help eliminate unnecessary duplications of tests or procedures. In the opposite situation, a review of the SOAP notes may indicate a test or procedure that has not been conducted yet.
It is important for professionals to use a format such as SOAP notes. Most medical, psychology, and social work fields are filled with jargon, abbreviations, and information that other professionals might need in the future. Without a coherent format for collecting this information, many notes would be very difficult to follow and it might be nearly impossible for someone to locate the information they need. Doctors do not always dictate their notes as SOAP notes, but many medical transcription agencies will have their transcriptionists write them up under the proper SOAP headings.
The reason the SOAP format has become a standard form of documentation is because the four sections (each of which will be reviewed in its own section) helps the note-taker recall and document all the relevant information, from their subjective notes and client history to their objective findings, and also to present their assessment of the problems and their plan for treatment. Without a standard format for these notes, information might be widely scattered and some reports might not include important information that might be needed later.